Sunday, December 29, 2013

As we enter the New Year, I like to reflect on where we've been and where we're heading in medicine. By far and away, this is the most tumultuous time I have ever experienced in health care. Doctors and nurses appear stressed and downtrodden, administrators are running scared, desperate to seem "value-added," and patients are scrambling to get seen in these last two days of 2013.

It's strange really.

I thought I'd try to make some realistic predictions of what patients should expect in the year ahead now that the "Patient Protection and Affordable Care Act" (PPACA) begins to sink it's tap root into the American medical system.

Triage

With the sudden expansion of the patient pool without a relative expansion of the physician pool, patients can expect a greater degree of triage to occur in medicine when they need to see a doctor. Triage will occur in many ways, but will fall along two lines: (1) treat the most urgent then (2) the most lucrative. Like it or not, these priorities will drive care for most medical facilities, especially our newly minted Accountable Care Organizations (aka, large hospital systems and care networks). Specialists will become purely proceduralists, internists and family practice doctors will see specialty follow-up and manage a team of nurse practitioners and "physician extenders," and these care extenders will become the front line care team for the more common ailments. In effect, follow-up specialty care will shift down the health care "food chain" to those less specialized in the name of improving "efficiencies" in health care. Some will argue this is cherry- picking lucrative patients and procedures, others will see this as a survival necessity for health care systems squeezed for revenue. Call it what you will, but realize it's another unintended consequence of the changes taking place in our health care market today.

Costs

There is no question that out-of-pocket costs (both direct and hidden) for health care will continue to rise for patients. Given the recent holiday season, most Americans are strapped for cash at the beginning of the year. But insurer's want their first installment for coverage as early as 10 January 2014. Hidden in their premium will be a 2% tax added to the every insurance plan's premiums, plus a $2 fee that goes to the Patient Centered Outcomes Research Institute (PCORI) created by our new health care law. As I've previously pointed out, the costly PCORI replicates functions already performed by the Agency for Health Care Quality and Research (AHRQ). The PCORI's budget is also scheduled to mushroom from $350 million to over $500 million annually in the years 2014-2019 with patients paying directly for this government agency thanks to this added fee. And what do they get in return from the PCORI? A wealth redistribution scheme to pay for even more "patient-centered" research redundancy.

Patient's take-home pay will also be reduced for middle-class individual tax filers earning more than $200,000 and families earning
more than $250,000. This is because they will pay an added 0.9 percent Medicare surtax on top
of the existing 1.45 percent Medicare payroll tax. They’ll also pay an
extra 3.8 percent Medicare tax on unearned income, such as investment
dividends, rental income and capital gains.

Finally, patients will quickly begin to understand what the terms "deducitible," "co-pay," and "co-insurance" mean when it hits their pocketbooks. My bet: they won't be happy about it.

Finally there's the issue of health insurance subsidies actually being tax credits. As reported in the Wall Street Journal:

The federal subsidies that will help many people pay for their coverage are actually tax credits tied to their income. They will go to people making as much as 400% of the federal poverty rate—in most states, $94,200 for a family of four in 2013. The more you make, the smaller your subsidy. The subsidy process "will all be part of the tax computation," says Judy Solomon, of the Center on Budget and Policy Priorities.

People can choose to receive these credits as monthly payments that flow to their insurers over the course of the year. But if they do this, and the subsidies turn out to be too large—if the consumer's income was higher than expected and she should have received a smaller subsidy than was dispersed—the recipient may need to repay at least part of the overshoot.

To avoid this situation, people should report major changes in income to their exchange website when they occur. Consumers who know in advance that their income may fluctuate can also take "less financial support," meaning a smaller subsidy upfront, or opt for a lump sum at year's end, says Cheryl Fish-Parcham, of the consumer group Families USA.

The government giveth and the government taketh away. Hey, someone has to pay for all of this bureaucracy.

Confusion

The difficulties experienced with the government's HealthCare.gov website will have their trickle-down effects felt in 2014. Given the number of vendors involved in development of the site, and their unwillingness to claim responsibility for the site's shortcomings, patients who registered on the site are likely to have little recourse for their difficulties readily apparent. Social workers will be saddled with helping these patients, along with their other duties. As if they don't have enough to do already.

Doctors will be introduced (perhaps "force-fed" is a better verb) to the "new and improved" ICD-10 coding scheme in 2014. With bureaucracy run amok in medicine, this is another hassle foisted upon physicians and care-givers. Compliance with the scheme is now a pre-requisite for physicians to be paid properly. Expect more screen time, cursing, and less patient-care time from your doctor as a result.

Insurers will be even more aggressive with denials based on insurance industry-developed "coverage decisions." Doctors and patients alike will continue to find this frustrating as insurers must assure their profit margins.

So as we begin the New Year, strap in, and get ready for Health Care 2014.

We're all going to be taken for quite a ride by the changes ahead. Rest assured, though, that there are still many doctors and nurses out there who will try to help ease their patients' burdens in such a stressful time for everyone.

Thursday, December 26, 2013

He complied and watched the computer screen in front of her read "Verified" in bold green letters.

With that, she looked up at him, shrugging her shoulders. "In my time here at the testing center, I'm still waiting for someone's identity to change between where you scanned your hand around the corner to here, just 10 yards away!" He smiled and she chuckled to herself. "Now pull out those pockets and let's seem 'em."

He complied.

"And the back pockets."

He turned. "Nothing. See?" he said.

"Now roll up your sleeves..."

Secretly at this moment, he was hoping a rabbit would appear, but complied again.

She handed him back his driver's license, rose from her computer, and said, "Follow me."

She led the way through a high security door toward a testing cubicle and quietly sat him at a screen that contained an image of his face shot earlier during his check-in process. She logged him in and there before him was a computer screen with a large American Board of Internal Medicine logo on it. She pointed out the silver headphones for to the left of the screen.

"Those are for audio, in case there's any of that on your test. And these to the right are noise-cancelling headphones if you prefer to wear them. Here's a white board for your use. Remember we are audio and videotaping everything. Whatever you do, don't raise your hand at any time unless you need us. Got that? We will come get you. Don't raise your hand otherwise. Any questions? Good luck..."

With that the escort left the room. He sat before the screen and placed the noise headphones on his head. The screen asked if he wanted to take a tour to familiarize himself with the features available on the software before starting his test. He clicked the "Yes, tour" button.

With that, the screen flickered and went black. He could hear the noise cancelling headphone suddenly begin to make sounds.

"Good morning, Dr. Phleps."

A picture appeared on the screen as the mysterious voice continued: "This is Dr. Richard J. Baron, the mastermind and ring-leader of the American Board of Internal Medicine that supports the security and secrecy procedures that you have just endured. He and his many well-paid collaborators have conspired to create a series of time-consuming and anxiety-producing tests and questionnaires designed to frustrate and instill fear in their professional membership. It has become clear that their processes are being promoted as a measure of physician excellence, when in fact, it sets a floor of performance standards for physicians while assuring the continuation of their administrative positions. Your mission, should you decide to accept it, is to pass your test so you can continue to demand accountability for the high salaries of these physician admistrators and the expense of this process that are soon to be imposed on physicians every two years. ... But remember, if you fail to pass, the Secretary will disavow and knowledge of your actions and perhaps your ability to practice medicine... Good luck. (This program will self-destruct in five seconds)..... * bbbbzzzzaaaaaaaappppppp *"

And with that, a small puff of smoke arose from computer and the screen went black briefly before it returned to the ABIM logo screen. The menu there again asked if he wanted to start the test. He clicked the "Yes, start the test" button on the screen. A contract screen appeared reminding him that he'd only be able to take the test if he agreed to be disavowed and reported to credentialling agencies if he divulged any test content or materials to anyone at anytime.

Realizing his wife would kill him for wasting thousands of dollars if he refused, he clicked "I Agree."

The first question appaered while the clock in the upper right corner of the screen began counting down. (A familiar theme song began playing in the background)

Tuesday, December 24, 2013

To all of the first respondersLaboring in the icy night in an hour of unexpected needWhile their children get tucked into bedIn the blanket sleepers...You are Christmas.To all the caregiversWho make Christmas happenEven when their hearts are heavy andMoments of rest too few…

You are Christmas.

To all the sufferingWho rise to the occasionWith a smile or a simple giftOr permission for others To celebrate without them…

You are Christmas.

To all the doctors, nurses and hospice workersWhose own trees go undecorated and gifts go unsentBecause it seems every yearThe hospitals are full at holiday time...

You are Christmas.

To all the parentsWho recapture the innocence of the seasonFor the sake of their childrenWith a song, a story, a silly ritual…

You are Christmas.

After all, it was never about the strong, the powerful, the rich,The proud,It was always about the humble, the faithful, the courageous,The quiet, hopeful ones.The scared young family standing in wonder at the manger,Trusting, holding faith, believing in good,

Sunday, December 22, 2013

I sit before the computer screen this morning, wondering "What should I write?" Yet as I thought about this, I realized I should really write about why I'm thinking about this.

My journey in this space of social media has been a bumpy one, full of ups and downs, ins and outs, obsession and indifference, all rolled up into one. Yeah, this sums up health care social media now, at least for me.

I began writing here in November 2005, not really knowing what I was doing. I thought of this space as a marketing space, then an information-to-patient space, then a social space ("gee, so many interesting people here!) and even an "inside view of medicine" space. In reflection, I really didn't know what the hell this space should be.

But then came 2006 and 2007, my father became gravely ill, and social media was a wonderful outlet for me to reflect on all of the emotions, memories, and experiences that such an event invokes. I found I loved writing. To this day, I use this space as a diary of that time in my life, and even found my eyes blurring a bit this morning as I re-read my earlier Christmas reflection of the events that occurred that year. Blogs, I've found, are really a good space for remembering certain events, certain times.

Later, I'm not sure where I went with social media. I signed up for Twitter during the Twitter-craze and learned about "tweets" and "hashtags" and all that stuff. I was amazed at how "up-to-date" I could be with the latest rage, outrage, sound bite and scandal in medicine. Heck, it my cell phone would come alive! Medicine is so, *ping* , i-n-t-e-r-e-s-t-i-n-g again! *ping* *ping*

As if the latest cell phone vibration, chirp, and flash was really what mattered and dull ol' medical care was just, well, glacially stimulating by comparison. What's not to like, right? You could be a teacher, provocateur, and health care social media detective! You, dear doctor, could make a difference!

But in reflection, reality's been very different than that.

I realize now that I am just one voice, one small individual in a the overcrowded mess that is the internet. Everyone is trying so hard to be heard. Entire social media companies are developed just to make sure you pay attention to your cell phone - just look at SnapChat, where if you don't immediately attend to your cell phone, the image, message or 10-second video is gone, never to be seen again. Pay ATTENTION, people!

This is not to say people's voices aren't important. In fact, many in this space say incredibly powerful things here. But I am seeing something very interesting on social media now, especially as it pertains to doctors' participation in this space: propaganda.

There are very savvy, well-organized forces on social media now. Everyone knows this is where the battleground of public opinion rests. So forces are marshaled, teams assembled to make sure the party line is towed.

I ask you, dear doctor, who much time do you have? So it is with social media in health care.

But recently in my evolution in this space, I realize I have matured. I don't come into health care social media starry-eyed any longer. It has a purpose. You can meet some remarkably thoughtful and insightful individuals here. You can make some pretty amazing friends. And you can get lost.

But I realize there's a purpose, too. People can tell a single, quiet, story here - a small, transcendent one, too.

Nowhere was this more visible than in the recent quiet, painful reflections of a young boy suffering with leukemia and the wonderful stories he and his parents shared in their blogs. These are not people providing propaganda, these were people with a purpose. These were people who realized what mattered. These were people who were an inspiration to us all.

As I reflect on all of this at Christmas time, I find it's more important to spend these short, dwindling, yet cherished moments with real life, not one manufactured by the media companies.

Time is precious. Family is paramount. And social media is, well, social media.

This holiday season I hope all of us will take time to pull our heads from our cell phones and computer screens. There some amazing things going on around us, some amazing stories of hope and courage, and things we really need to appreciate. Most of those things aren't represented by bits and bytes on an iridescent screen, but rather what we take for granted every day, if we dare to look up.

Thursday, December 19, 2013

"As a third year medical student, I would also argue that this is creating a generation of dumb doctors. My school (average US MD school in the Midwest) has almost abandoned teaching physiology and understanding. We have the virtues of guidelines shoved down our throats instead. Recognize a pattern, apply the appropriate guideline. That's medical school these days...."

Tuesday, December 17, 2013

““A totalitarian state is in effect a theocracy, and its ruling caste, in order to keep its position, has to be thought of as infallible. But since, in practice, no one is infallible, it is frequently necessary to rearrange past events in order to show that this or that mistake was not made, or that this or that imaginary triumph actually happened.”
- George Orwell

* * *

The brushed, steel belly of the scalpel blade pressed down on the orange antibacterial film and released the subcutaneous yellow fat globules surrounded by small beads of red blood. The movement of his hand was fluid, purposeful, and without hesitation. The electrocautery pen carefully seared the points where blood appeared. A retractor was installed to spread the tissues farther apart as he worked quickly to gain access to the tissue plane just above the muscle. His movements were deft for he knew they were watching.

The Capitol's campaign to ensure perfect outcomes was well underway. They had installed cameras throughout the hospital just four short years before: in the halls, the changing rooms, at the scrub sinks, and in the operating rooms. The Capitol had discovered that the operating room was like yesterday's boxing ring, or even farther back in the mists, the Coliseum. In the New World unpredictable events and venues that stirred primitive passions were few - and yet they were longed for as they were feared. This context explained the popularity of the annual Hunger Games, created as punishment for the destruction of District 13 by a failed patient uprising after the health care financial apocalypse. Each year,one male and one female physician "tribute" from each of the surrounding twelve Districts were selected by lottery and performance metrics to fight each other to the death. Providing spectators with a window into the drama, and ensuring that drama by creating just the right conditions, gave spectators a sense of aliveness that they barely remembered, and just enough to stimulate fear. The Games also served as the perfect venue to deflect blame from the Capitol's expedience in sacrificing people for their own avarice.

The call had come after a full, exhausting day. The patient had presented to the Emergency Room only two weeks after open heart surgery for coronary disease and to replace his critically-narrowed aortic valve. The surgeon-tribute wasn’t sure why his conduction system should fail this late after surgery but it didn’t matter; his heart rate had slowed to a dangerous 19 beats per minute. His blood pressure, while low, remained stable. A quick review of this medication list disclosed the mandatory heart medications that included an anticoagulant for the heart valve and antiplatelet agents for his coronary disease. No heart rate slowing medication was being used so the Capitol's appropriateness indication to proceed with the procedure was indisputable. It was also fortunate that the anticoagulant the patient was taking hadn’t thinned his blood too far. He decided to take him to the operating room directly. It was 3 am.

Meanwhile, back at the TV studio: “I tell you, Frank, every year the footage gets better and better! How did your team know that these untenable circumstances would result in such great late night viewing? This is so exciting!”

The call team had been called, but was short-staffed. Efficiency meant lower cost, fewer people, and longer work hours. The designated scrub tech had car trouble and would be delayed. So the other technician and nurse worked feverishly to ready the room. The call had already been made to the device representative who brought the new pacemaker hardware, but he was barred from entering the operative suite for he was not part of the medical team. Rules were rules. The patient, of course, was agitated, gasping for breath. The doctor worked as fast as possible to establish pacing – the air was tense.

“Are you kidding? I love seeing this, don’t you? The nervousness of his voice! The anxiety! The skeleton crew at night! Beautiful! I’m not sure it gets much better!”

John had no idea why his car wouldn’t start that night (but the spectators did). He turned the key again and again, only to hear the engine spit in return. He slammed his hand against the steering wheel, frustrated that he was unable to keep his car tuned for poor weather. But such concerns were luxuries now that hospital budgets were tight thanks to the Capitol’s Bundled Payments for Care Improvement campaign. Finding a ride to work became the imperative. He raced back into the house to wake his wife in a panic, asking her whom he might call to give him a ride – they each knew the consequences of failure. They called their neighbor and woke him from a sound sleep. The pressured nature of their voices convinced him to loan them his car and five precious minutes later, he was off to work calling ahead to notify them of the delay.

At the hospital, Chloe answered John's call as she sat behind the monitoring console. She was one of the best young technicians to graduate from her training school. Still, her hospital’s equipment was not up to date because maintenance contracts were left to expire in these cost-saving times. Still, although the software it ran was now several versions old, it still reliably fed data to the Capitol's chargemaster. She looked down at the dust on the keyboard. Seeing this, it was clear she couldn’t enter the room to assist because the risk of surgical contamination was too great.

The surgeon-tribute was glad he’d placed two venous sheaths to gain vascular access, rather than just one. He had successfully placed both pacing wires through the sheaths to the patient’s right atrium, ready to be secured to their appropriate chamber. But he needed a softer shaping wire – the stylette – to insert into the inner lumen of the pacing wire. Without the stylette, the pacing wire had the consistency of a well-cooked spaghetti noodle. With it, he could place the pacing wire to its appropriate chamber. As he turned, his eyes left the surgical field for just a moment. He scanned the table crammed with scattered instruments and hesitated briefly as he located the proper stylette.

A hush fell over the audience as they saw the opening. They leaned forward in anticipation, reveling in their luck to see such a careless mistake.

John leaned his head in the room to notify them he’d finally arrived and would assist as soon as he could change. The surgeon smiled, acknowledging his dogged efforts to arrive as quickly as humanly possible. He turned to the field and shaped the stylette to the perfect curvature that would allow him to affix the pacing wire to the lower, primary pumping chamber of the patient’s heart. He focused his blurring vision to place the tiny stylette in the endhole of the pacing lead. Chloe broke the silence of the moment: “Hey guys, did an electrode fall off?”

The doctor looked up briefly to see atrial P waves dancing across the monitor screen without any corresponding ventricular electrical activity. With that, his worst nightmare was realized. The patient began posturing on the table, his head thrown back beneath the drapes, his arms slowly but powerfully raising. The surgeon leaned forward to grab the patient while trying to control the leads, stylette, and surgical wound sterility. The patient began violently thrashing beneath the drapes, his face turning blue and lips crimson as saliva and exhaled gases mixed into a frothy spraying mess. He was seizing uncontrollably. His once steady escape rhythm had chosen this unfortunate moment to stop.

If the surgeon was expecting help from a sponsor it was unlikely to be forthcoming. Just yesterday, the tribute's most likely supporter/sponsor, Sylvia, a well-to-do matriarch from the Central District, had noticed an incipient sign of aging on her neck – subtle crepe-like thinning of her skin, this despite her rigorous adherence to all of the Wellness Initiatives the Capitol had advertised. She had reason to hate, didn't she? She'd been failed one too many times. She remembered sitting with her 65 year old mother gasping for air in one of those infernal assembly-line clinics with the young doctor glancing at the red, flashing "Do Not Admit" guideline on the computer screen as he sent them home with morphine with that flat, dead, passive expression on his face! He didn't care then and so she wouldn't care now!

Seconds felt like hours as the patient's body slowly twisted sideways. The nurse did all she could to support his weight and keep him from falling. The surgeon, too, felt helpless as the powerful frame shook uncontrollably beneath the drape. The restraints tethered his arms but his involuntary leg movement forced him further sideways. John felt powerless as he watched from the door. Finally, he could watch no longer and ran into the room just as the patient fell to the floor.

The idea of the website is a simple but important one: "We have few role models and few realistic stories about living with a
less-than-perfect body, or less than perfect health. How we choose to
deal with the cards that life gives us is what this site is all about." About half of the slogans used on the various t-shirts sold by the site were donated by our patient-customers with proceeds directed to the charity of their choosing. All proceeds that we receive from the sale of these shirts (about $3/shirt) is donated at the end of each year, proportional to the themes of the t-shirts sold. (By the way, we're always looking for new ideas for shirts.)

Since we do not purchase advertising, this blog serves as our "ad space" for MedTees.com. This will be the only blog post used this holiday season to promote the site, so if you're looking for something different to offer a friend who's been through a tough time medically this past year, consider a MedTee.

A recent essay entitled "Understanding the Customer and the New MOC Changes" by David May, MD, PhD, chair of the Board of Governors and secretary of the Board of Trustees for the American Board of Cardiology, was published online and tugs at our heartstrings by describing the Maintenance of Certification (MOC) secure examination in Cardiovascular Diseases as "flawed but reassuring measure of our competence for the real customer here … our patients and their families who trust us with their very lives."

I read this piece after recently completing the MOC process in both cardiology and cardiac electrophysiology for the third time. After devoting hundreds of hours preparing for an impersonal timed computer test yet again, I couldn't help but wonder if physician scientists should ever accept a "flawed" process as acceptable for our ourselves or our patients. Imagine the implications to scientific inquiry and the process of challenging (and thereby improving) the educational process if we did: we might have to accept media reports to justify the process so we can make it even bigger.

Patients deserve transparent quality metrics of care provided by their doctors and the American College of Cardiology (ACC) has been a unique leader in bringing measurable care metrics to the public with the development of their NCDR databases. Yet instead of turning to these real life metrics of care delivery, it seems the leadership of the ACC also feels compelled to sell a "flawed" educational testing construct to its members too. Is this decision based on a self-imposed imperative to dispense social justice at the bedside or more for the direct financial renumeration received by the officers of the College or it's parent, the American Board of Medical Specialities?

I believe there is merit to becoming Board Certified in a subspecialty once. A baseline of knowledge is assessed by this process. But the move to the current model of "maintaining" certification through complicated, costly, and unproven methods of survey completion, administrative and academic busy-work, followed by a timed multiple-choice computerized test overreaches into unproven areas of quality assurance.

To me, a better measure of physician competence and quality would be this: Board Certification once followed by disclosure of the total number of patients treated or the total number of procedures performed pulled from databases akin to the NCDR databases in development. Such a method would align with current documentation requirements for assuring quality patient care and would avoid alienating busy physicians already faced with unprecedented regulatory scrutiny, steep pay cuts and loss of autonomy.

Pretending that the MOC process is a better method to assess competence rather than one's clinical experience in delivering real, live, clinical care feeds unrealistic expectations and may even promote a false sense of security to our patients.

What patients and their doctors deserve (and need) is verifiable data, not propaganda.

Featured Post

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.